Thanks for sharing this! You’ve convinced me that policy advocacy in the US could be really cost-effective, simply by leveraging the huge resources at stake. My main objection is to the ballpark 2-3 QALY gain for each person who receives food aid or health insurance. I understand that these are just simple calculations for illustration, but I think that added complexities will tend to make this estimate go down a lot:
I’d be surprised if, among Americans, food security alone is worth this much per person. Health outcomes in the US are horrendously unequal because of a nexus of strongly-correlated factors that also include poverty, unhealthy lifestyles, healthcare, drugs, etc. Removing a single one may not do much.
You’re assuming that any improvements in benefit-claiming lasts a long time (many years of food aid are required to ensure a child is never food insecure). In reality, counterfactual effects will decay over time. Less so for structural changes that make it easier for people to claim benefits.
Another point is that diverting public funds comes at a counterfactual cost. What would have happened to that MediCal money that would have gone unclaimed until your expansion advocacy? Maybe something less cost-effective (like schools, which form a third of CA’s budget), but with a non-negligible impact that should be subtracted from the effect of MediCal expansion.
One possibility to come up with additional funds would be to pass a tax on the wealthiest to pay for this expansion. Eg, a property tax on homes valued at more than $5M, or a capital gains tax on Retirement portfolios over $5M. Lower wealth limits will introduce more opposition from voters.
Agree that this would be great and agree that it would face opposition.
QALY Assumptions I agree, I was reflecting on the arguments and also felt that the QALY assumptions I made were very uncertain. The reasoning you point it is very sound; the 3 year estimate could easily be two orders of magnitude off. That would still leave it in a range worth looking at (I think Givewell targets something like $70 per QALY), but there’s a big question about how we could get more certainty on the impact.
Most studies on the subject are observational, and I think this points to the need for government programs to actually do some experimental analysis. But since these are programs passed by law, it might be ethically tricky to provide access to a benefit for one county and not for another. Looking at families who utilize a benefit vs not is also not experimentally sound.
Counterfactual impact
That’s a great point. I’m actually not sure how those funds get handled. I think they are typically earmarked in the budget, so they might not be automatically diverted. On the other hand, when legislators are creating a budget, they might factor in that 15% of eligible people won’t use a benefit.
Increasing budget with taxes on the ultra-rich
Yeah, I’m really curious about how hard this would be. Theoretically, a very rich person and their friends might band together to spend against this sort of proposition, but I’m not sure they would? I think a lot of progressive taxes fail because they their income limits are too low, and so there’s a significant voting block which is loud and well-organized, who will call their representative in opposition. Since there is a lot of concentrated wealth at the top, it makes sense to me to focus on going after that money. However, I have no idea how much a tax like the one proposed would actually raise.
Yes for me the 2 QALY benefit seems really unlikely, I would be instinctively thinking an order of magnitude less than that.
I also find a 50 percent chance of success in any kind of campaign like this pretty unlikely too, given the history of policy like this not getting through and opposing powers. Would be guessing more 5 to 15 percent range.
Nice article interesting one! Am a big fan of advocacy and think it can be super cost effective!
Thanks for sharing this! You’ve convinced me that policy advocacy in the US could be really cost-effective, simply by leveraging the huge resources at stake. My main objection is to the ballpark 2-3 QALY gain for each person who receives food aid or health insurance. I understand that these are just simple calculations for illustration, but I think that added complexities will tend to make this estimate go down a lot:
I’d be surprised if, among Americans, food security alone is worth this much per person. Health outcomes in the US are horrendously unequal because of a nexus of strongly-correlated factors that also include poverty, unhealthy lifestyles, healthcare, drugs, etc. Removing a single one may not do much.
You’re assuming that any improvements in benefit-claiming lasts a long time (many years of food aid are required to ensure a child is never food insecure). In reality, counterfactual effects will decay over time. Less so for structural changes that make it easier for people to claim benefits.
Another point is that diverting public funds comes at a counterfactual cost. What would have happened to that MediCal money that would have gone unclaimed until your expansion advocacy? Maybe something less cost-effective (like schools, which form a third of CA’s budget), but with a non-negligible impact that should be subtracted from the effect of MediCal expansion.
Agree that this would be great and agree that it would face opposition.
QALY Assumptions
I agree, I was reflecting on the arguments and also felt that the QALY assumptions I made were very uncertain. The reasoning you point it is very sound; the 3 year estimate could easily be two orders of magnitude off. That would still leave it in a range worth looking at (I think Givewell targets something like $70 per QALY), but there’s a big question about how we could get more certainty on the impact.
Most studies on the subject are observational, and I think this points to the need for government programs to actually do some experimental analysis. But since these are programs passed by law, it might be ethically tricky to provide access to a benefit for one county and not for another. Looking at families who utilize a benefit vs not is also not experimentally sound.
Counterfactual impact
That’s a great point. I’m actually not sure how those funds get handled. I think they are typically earmarked in the budget, so they might not be automatically diverted. On the other hand, when legislators are creating a budget, they might factor in that 15% of eligible people won’t use a benefit.
Increasing budget with taxes on the ultra-rich
Yeah, I’m really curious about how hard this would be. Theoretically, a very rich person and their friends might band together to spend against this sort of proposition, but I’m not sure they would? I think a lot of progressive taxes fail because they their income limits are too low, and so there’s a significant voting block which is loud and well-organized, who will call their representative in opposition. Since there is a lot of concentrated wealth at the top, it makes sense to me to focus on going after that money. However, I have no idea how much a tax like the one proposed would actually raise.
Thanks so much for the great points!
Yes for me the 2 QALY benefit seems really unlikely, I would be instinctively thinking an order of magnitude less than that.
I also find a 50 percent chance of success in any kind of campaign like this pretty unlikely too, given the history of policy like this not getting through and opposing powers. Would be guessing more 5 to 15 percent range.
Nice article interesting one! Am a big fan of advocacy and think it can be super cost effective!